MEDICARE: BLUEPRINT PEDIATRIC THERAPY, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	3530	IA

General Provider Information

NPI Number	:	1669877056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEPRINT PEDIATRIC THERAPY, PLC

Provider Business Mailing Address
First Line	:	2387 MEHAFFEY BRIDGE RD NE
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-9348
Country	:	US
Telephone Number	:	319-333-4490
Fax Number	:

Provider Business Practice Location Address
First Line	:	2387 MEHAFFEY BRIDGE RD NE
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-9348
Country	:	US
Telephone Number	:	319-333-4490
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. RACHEL LYNN KONGSHAUG
Credential	:	PT, MPT, PCS
Telephone Number	:	319-333-4490

Provider Enumeration Date	:	10/27/2014
Last Update Date	:	10/27/2014

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